Antidepressant induced suicidal ideation

There has long been a view that patients who are recovering from depression are at greater risk of killing themselves than patients who are severely depressed. This paradoxical response has been attributed to a quicker resolution of depressive retardation than of accompanying suicidal ideation. This supposedly leaves subjects who are suicidal with more energy and drive to set about effecting their own demise (Kendall and Zealley, 1988; Gelder et al., 1989). ‘This explanation has a certain trd hoc quality to it. While it may account for some suicides in individuals recently put on antidepressants, it seems unlikely to be the only mechanism that might lead to suicide. A recent report by Teicher et al. ( 1 990) of prominent suicidal ideation commencing several days after starting fluoxetine suggests a quite different picture. Describing six cases, they reported that while the depressed mood of subjects began to lift on fluoxetine, they became suicidal, where they had not been before, and in a manner that suggested they had become obsessed with the idea of suicide. In attempting to account for their findings, Teicher et al. (1990) noted that all subjects became akathisic and postulated that the development of akathisia might be in some way related to the development of suicidal ideation. There are a number of difficulties with this report. One is the fact that all the subjects involved had rather complicated clinical pictures with some being diagnosed as having borderline personality problems. A second is that the dose of fluoxetine used was higher than is now generally recommended. A third is that many of the subjects were taking concurrent psychotropic medication and hence ascribing the problem solely to fluoxetine seems unwarranted. We report on two subjects. One had a reaction